Report: Chinese Academy of Medical Sciences – Diagnosis and Treatment of Coronavirus Pneumonia

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The latest report: In the Chinese province of Hubei, the epicenter of the epidemic, the number of new infections has marked a second consecutive increase – in total, in China, the total number of infections has risen to 80,409 while the victims are 3,012.

The incubation period for new coronavirus pneumonia is on average about 7 days, the shortest is 2 to 3 days and the longest is 10 to 12 days. Human-to-medical infections have occurred and there is a community-based transmission range.

The epidemic is mainly transmitted through the respiratory tract, the virus can change and the epidemic is at risk of further spread.

How is new coronavirus pneumonia diagnosed?

I bring you the Quick Guide for the diagnosis and treatment of new coronavirus pneumonia prepared by the expert group of the Tongji hospital and the strategy and instructions for managing the New Coronavirus 2019 of the Union Coronavirus 2019 at the University Hospital of Tongji Medical College of Huazhong University of Science and Technology.

Tongji Hospital Expert Group “Quick Guide to Diagnosing and Treating New Coronavirus Pneumonia”

The expert group of Tongji Hospital, based on first-hand data from the first group of patients diagnosed and treated by the main medical institutions in Wuhan, including Tongji Hospital, developed the ” Quick Guide for the diagnosis and treatment of pneumonia from new coronavirus “.

Pathogenic characteristics of the new coronavirus

After analysis of the viral sequence, it is  assumed that the natural host of the new coronavirus disease may be bats. 

Unknown intermediate host vectors are likely to exist during bat-to-human transmission. 

According to SARS-CoV and MERS-CoV studies, coronaviruses are heat sensitive and kept at 56 ° C for 30 minutes: diethyl ether, 75% ethanol, chlorine-containing disinfectants, peracetic acid and chloroform can effectively inactivate the virus.

Chlorhexidine cannot effectively inactivate the virus.

The onset of new coronavirus pneumonia manifests itself primarily with fever

From the point of view of clinical manifestations, the onset of new coronavirus pneumonia manifests itself mainly with fever, which can be combined with mild dry cough, fatigue, breathing difficulties, diarrhea and other symptoms such as runny nose and sputum.

Half of the patients developed wheezing after a week and severe cases quickly transitioned to acute respiratory distress syndrome, septic shock, difficult-to-correct metabolic acidosis and coagulopathy.

Some patients exhibit mild onset symptoms and may not exhibit clinical symptoms such as fever and usually recover after 1 week. 

Most of the patients have a good prognosis, but some of them have become seriously ill and died.

In the initial phase of imaging, smaller irregular shadows and interstitial changes appeared and the extrapulmonary bands were evident. 

Multiple emery infiltrations have been noted in both lungs.

In severe cases, lung consolidation and pleural effusion are rare.

In addition to imaging results, patients may also have normal or reduced peripheral white blood cells in the early stages of onset, decreased lymphocyte count and increased liver enzymes, muscle enzymes and myoglobin in some patients. 

Most patients had elevated C-reactive proteins and erythrocyte sedimentation and normal procalcitonin. 

In severe cases, the DD dimers increase and the lymphocytes progressively decrease.

What are the symptoms of fever patients with suspected infection ?

This new type of coronavirus pneumonia .

The population lacks immunity to this virus which spreads quickly in crowds.

If patients are exposed to a large amount of virus or the body’s immune function is poor, infection becomes very likely.

Based on previous diagnosis and treatment experience, there was a history of travel or residency in Wuhan within 2 weeks before the start; o fever patients with Wuhan respiratory symptoms within 14 days prior to onset or cluster onset; the patient had a fever with pneumonia.

Imaging features; normal white blood cells or decreased in the initial stage of the disease or a decrease in the lymphocyte count can be considered suspicious cases.

Based on meeting the criteria for suspect cases, sputum, throat swabs, lower respiratory tract secretions and other samples can be diagnosed by real-time fluorescent RT-PCR detection of positive 2019-nCoV nucleic acid.

For all suspect cases, medical isolation is required in SITU, while for mild patients it is possible to make observations in the clinic or at home.

All patients returning home for observation should request that they return to the designated hospital for intensive treatment as soon as disease deterioration occurs.

Patients with severe and critical cases must be hospitalized.

Diseases to be identified for new coronavirus pneumonia

Since patients with this type of pneumonia often have a fever, diffuse and invasive lesions in the lungs must be distinguished from other types of pneumonia, such as:

  • bacterial pneumonia – often have upper edema and especially a single lung, coughing can be purulent,
  • non-viral pneumonia such as mycoplasma and chlamydial pneumonia,
  • viral and other differentiated pneumonia.

Many viruses can cause pneumonia, such as the flu virus, respiratory syncytial virus, rhinovirus, adenovirus, etc.

They can cause pneumonia, but these virus infections have a relatively low probability and the number of pneumonia is relatively low.

Patients with the new coronavirus infection have a very high case of pneumonia.

The probability is higher and the infectivity is stronger than other viral pneumonia, it must also be distinguished from interstitial lung diseases, in particular acute interstitial pneumonia, mainly from epidemiological and imaging manifestations.

Attention should be paid to the application of antiviral, antibacterial drugs and hormones

At the moment, there is no specific antiviral drug for the new coronavirus and the treatment is mainly symptomatic and supportive. 

Avoid blind or inappropriate antimicrobial treatments, especially in combination with broad spectrum antimicrobials.

For mild patients, it is recommended to administer intravenous or oral antibacterial drugs, such as moxifloxacin or azithromycin, based on the patient’s condition. 

For severe or critically ill patients, empirical antimicrobials are administered to treat all possible pathogens. 

For patients with sepsis, antimicrobials should be administered within one hour after the initial patient assessment.

Glucocorticoids are a “double-edged sword” for viruses.

On the one hand, it inhibits the body’s immune function and can cause the virus to spread.

On the other hand, it can reduce lung inflammation and help improve the symptoms of hypoxia and breathing difficulties, unless there is a special reason.

Routine corticosteroids should be avoided.

Glucocorticoids can be used for a short period of time (3 to 5 days), as appropriate, based on the patient’s wheezing and chest imaging progress. 

At the moment there are no specific antiviral drugs. 

The alpha-interferon nebulizer, lopinavir / ritonavir and other medications were used.

If there is a history of endemic epidemiology or other risk factors related to infection (including travel history or exposure to animal flu virus), empirical therapy should include neuraminidase inhibitors (oseltamivir) or membrane fusion inhibitors (Azerbaijan by Dole).

Older and pregnant women progress relatively quickly

The new type of coronavirus pneumonia can occur in people with low immune function and normal immune function and has a certain relationship with the amount of exposure to the virus. 

If you have been exposed to a large amount of viruses at the same time, you may get sick even if your immune function is normal.

For people with poor immune function, such as the elderly, pregnant women or people with liver and kidney dysfunction, the disease progresses relatively quickly and the severity is higher. 

Of course, many people with normal immune function cannot be taken lightly due to severe inflammatory reactions that can cause ARDS or sepsis after infection.

Punctual follow-up of discharged patients

At present, some patients have been treated and discharged, especially for mild patients.

Before discharge, nucleic acid tests should be performed routinely. The nucleic acid test is negative for 2 consecutive days and clinical symptoms are significantly alleviated or imaging performance has significantly improved.

Follow up. 

During follow-up, attention should be paid to preventing recurrence of infection and quarantine at home for a period of time to ensure complete recovery.

Wuhan Union Medical College strategy and instructions for managing new coronavirus infections 2019

Zhang Jinnong Emergency Medicine Department, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China

At the moment, it is necessary to continue to observe how the Wuhan 2019-nCoV epidemic will develop. 

There is no clinically proven effective treatment for the treatment of coronavirus (CoV) infection. Some newly marketed drugs are based primarily on SARS-CoV in vitro experiments. 

The lack of valid support for clinical research has led to several therapeutic approaches.

As a result, we cannot blindly copy and use the recommendations of authoritative organizations as a guide. 

This situation means that the treatment plans will be used locally and made available online later.

We can learn from the results of basic research and other respiratory viruses, such as the pathogenesis of influenza viruses, to design clinical treatment methods for CoV and during this 2019-nCoV epidemic.

From first observation to subsequent design, high-level clinical trials we can say that the SARS-CoV epidemic in 2003 was controlled through a variety of global measures, including setting up a clinic for fever is one of the effective measures to triage of suspect patients. 

After more than a month of experience in dealing with the Wuhan 2019-nCoV outbreak in Wuhan, we have established the following clinical strategies  for treating the various clinical pictures and people suspected of having been infected.

1. Fever <37.3 ° C, only chills (often appear first), sore throat, cough and no breathing difficulties:

CRP <10mg / L, only blood routine + C reactive protein (CRP), pay attention to the absolute value of the lymphocytes.

If the absolute value of the lymphocytes is greater than 1.1 G / L, thoracic CT and virological tests will not be performed at this stage. 

Doctor’s advice: strict isolation at home, not suitable for follow-up, wear a mask when going out for medical treatment. Azithromycin (cemetil) or amoxicillin can be taken orally.

Note: early patients cannot have fever, only chills and respiratory symptoms, but CT can show limited opacities (as shown below).

This is a 57 year old male. In the first phase of onset, there were only chills: after 2 days, there was a low afternoon and moderate fever (37.5 ° C-37.7 ° C), lower respiratory secretions (sputum) 2019-CoV positive, taking anti-Granium antibiotics and Abidol 3 After a few days the symptoms eased.

The setting of the upper limit of body temperature is a rule that can be followed by doctors who supervise this type of patient and are subjected to social units for home isolation and dynamic observation. 

In light of the current situation, it is necessary to calm patients ‘fear: prescribed oral azithromycin (Xisume) or amoxicillin can not only soothe patients’ emotions, but also treat upper respiratory tract infections.

2. Fever> 37.3 ° C, sore throat and cough, but no wheezing:

Blood routine + CRP + flow A and B and nucleic acid of the syncytial virus + pulmonary CT.

Note: fever> 37.3 ° C as the limit value cannot effectively identify uninfected patients, but is stricter than the limit set by the World Health Organization (WHO) for body temperature ≥38.0 ° C. 

In the current situation, the whole of society has mobilized, the burden of medical staff on monitoring the level of manifestation of fever will gradually decrease and rigorous standards will help cut the transmission of mild patients into the crowd effectively.

3. If lung CT indicates viral pneumonia:

What to do ?

  1. The personal medical assistant who took the electronic medical record and the CT plate of the chest must take a series of photos with the mobile phone. The CT plate must be positioned on the reading lamp and must be photographed with high quality images for easy identification. An image with 6-8 fields of view is the best, so you will have to send the acquired images via an App … like WeChat to the group of experts.
  2. Consult the expert on duty. The mobile phone can be a source of transmission and a high resolution mobile phone dedicated to consultation and to collect clinical data should be provided – Personal phones are disabled.

Note: In the face of the epidemic, experts appear abnormally inadequate. In order to avoid infectious experts and provide efficient diagnostic procedures, first-line doctors provide experts with high-quality medical history and chest X-ray CT scans to diagnose and judge the condition is very important. 

Some members of infected medical staff do not rule out infection through contact with the cell phone.

4. After determining viral pneumonia:

(1) Oral moxifloxacin (Bai Fu Le) 0.4 Qd or levofloxacin (Clopidine) 0.5 (no history of allergy or intolerance to quinolone) + oseltamivir (Duffet or Covey) 75 mg Bid, 5 days;

Or (2) Intravenous infusion of ceftriaxone (Rochefin) 2.0 (or Ertapenem 1.0, limited to night skin tests and patients who cannot tolerate quinolone) + 250 ml saline solution + Azithromycin (hisume) Oral, 0.25 Qd, double the first dose. Place in isolation and request the 2019-nCoV test.

Note: the above are the antibiotics that we recommend using in combination with existing products in hospitals.

It is very important to note that the same drug has large differences in efficiency between the various pharmaceutical brands, therefore the commercial names of the drugs that are used are listed.

Influenza virus infection causes severe damage to the respiratory defense mechanism and can inhibit the body’s ability to eliminate the virus [1].

Protein kinases produced by Streptococcus pneumoniae and Staphylococcus aureus can promote the spread of the influenza virus [2,3].

 In the current situation, the results of influenza research can be used as a reference and in clinical practice it can be observed whether anti-positive bacteria can delay disease progression. 

In community infectious pneumonia (CAP), atypical pathogens and typical and atypical pathogens are also covered according to guidelines.

Recently, the Wuhan Xiehe Hospital AB nucleic acid test (January 23, 2020 statistics) showed that the positive rate of AB nucleic acid in adults was 47%. Much of the second class. 

The positive 2019-nCoV rate of a small number of medical personnel has recently been 8%. 

The individual cases of B-flow and 2019-nCoV are double positives, which does not exclude co-infection. The current pandemic rate is reasonably low.

We therefore recommend that you never give up anti-adenitis treatment. 

5. If CT excludes viral pneumonia or other pneumonia:

Treatment according to method 1, plus amoxicillin 1.0 Tid by mouth. After the temperature has dropped, the doctor must order to: strictly home insulation, not suitable for follow-up, wear a mask when going out for medical treatment.

Note: prospective studies of CAP etiology in China show that the order of antibiotics sensitive to Streptococcus pneumoniae: respiratory quinolone (close to 100%)> ceftriaxone (70%, original preparation)> amoxicillin (50%).

Amoxicillin can be taken orally since patients cannot be absolutely excluded in early infection or limited to the upper respiratory tract 2019-nCoV, use amoxicillin in time to prevent the evolution of the disease. 

This requires clinical observations to help reduce the epidemic.

6. If CT indicates viral pneumonia with dyspnoea and hypoxia (blood oxygen saturation <93% during air inhalation):

Oxygen is recommended, the patient is hospitalized in an isolation ward and the risk of translocation is assessed. 

If you temporarily do not have a bed, you must request the 2019-nCoV test.

Anti-infection: if oseltamivir and moxifloxacin have been used in the initial phase, the condition still worsens:

(1) Abidol (Qiaoxiao) + Taijixin (Nanofloxacin) orally or

(2) Abidol Dole + linezolid orally or intravenously. Vancomycin can also be used in place of linezolid.

Vancom is less effective in treating lung infections and has potential kidney damage, but is much cheaper.

Note: Anti-virus + anti-streptococcus pneumonia + anti-staphylococcus aureus is the main program that we currently recommend.

 Qixiao (Abidol) has an in vitro anti-SARS coronavirus effect and is assumed to be effective. 

A small number of patients with the 2019-nCoV infection found benefit after its use (the level of evidence is not high).

Flu studies have shown that the percentage of patients with S. pneumoniae and Staphylococcus aureus in the upper respiratory tract increases and that medical personnel are in a drug-resistant environment, with a high rate of drug-resistant strains such as S. pneumoniae. and S. aureus.

This may be one of the reasons for the susceptibility of medical personnel. 

Broad-spectrum antibiotics that are ineffective against these two positive bacteria will lead to the dominant growth of Streptococcus pneumoniae and S. aureus, but early application will be harmful. 

Linezolid has a potential inhibitory effect on blood cells such as platelets and can also lead to neuritis.

Quinolone, azithromycin and abidol have potential side effects on the heart.

Combined use can cause heart failure.

7. Heat treatment:

If the body temperature is above 38.5 ° C, the oral ibuprofen solution can be used to reduce the fever.

Nonsteroidal drugs have anti-inflammatory effects, but they can cause delayed detoxification (based on flu research). 

If the body temperature drops below 38 ° C, too low a temperature does not favor the antiviral action.

Ibuprofen can help cool down the temperature, suppress inflammation in the lungs, but it has the potential to generate gastric damage by increasing the chance of blood clots. 

Intolerants use compound aminopyrine or physical cooling. 

Cold medicines like Tylenol can also reduce fever.

8. Treatment for cough and sore throat:

You can use: honey, symptomatic mint candies, Lian Chuanbei honey cream ointment. 

Hot chicken soup also helps relieve symptoms.

Dextromethorphan has proven ineffective and should not be recommended. 

Hot chicken soup can increase body temperature and increase the body’s anti-virus – the salt in chicken soup can increase phlegm.

9. Determine remission:

Local symptoms of viral upper respiratory infections take at least 2 weeks to resolve completely.

10. Determine the outcome of the condition:

Chest CT cannot be used in the short term.

If the symptoms alleviated significantly, CT lesions increased in density and showed signs of fibrosis, the apparent disappearance of halos is an indication of improvement.

Improvement of symptoms and changes in CRP are of great importance. 

The value of procalcitonin (PCT) in determining bacterial co-infection is limited and is for reference only.

References

1. McCullers JA. Nature Reviews | Microbiology 2014, 12: 253 

2. Steinhauer DA. Virology. 1999 May 25; 258 (1): 1-20 

3. Callan RJ et al. J. Virol., 71: 7579 -7585, 1997 4. Palacios G, Hornig M, Cisterna D, et al. PLoS One. 2009; 4 (12): e8540. 5 Randolph AG, Vaughn F, Sullivan R, et al. Pediatrics. 2011; 128 (6): e1450-e1458. 6. Reed C, Kallen AJ, PattonM, et al. Pediatr Infect Dis J. 2009; 28 (7): 572-576. 7. Hageman JC, Uyeki TM, Francis JS, et al. Emerg Infect Dis. 2006; 12 (6): 894-899

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